A national study of psychiatrists' professional activities.

OBJECTIVE AND METHOD: A mail survey was conducted in 1988-1989 to study the professional activities of U.S. psychiatrists. Data from the 19,431 active respondents are reported. RESULTS: Nineteen percent of the psychiatrists were women, an increase from the 17% reported in 1982. The median age of the respondents was 50 years. Nearly one-third of the respondents expressed interest in each of the following areas of subspecialization: adolescent psychiatry, substance abuse, geriatrics, and consultation-liaison psychiatry. More than one-fifth reported formal fellowship training in child/adolescent psychiatry. The psychiatrists worked an average of 48 hours per week--two-thirds in direct patient care--in an average of 2.3 different settings. The proportion of psychiatrists reporting private practice as their primary work setting showed a marked decline from 53% in 1982 to 45% in 1988. There was an increase from 4% in 1982 to 11% in 1988 in those whose primary work setting was a private psychiatric hospital. The typical caseload was over 60 patients, with roughly half that number seen each week. For inpatients treated, the two most common diagnoses were affective disorders and schizophrenic disorders. In a typical week psychiatrists treated about one-half of their outpatients with individual psychotherapy; three-fifths of these were also treated with medications. The average net income for psychiatrists working 35 hours or more per week was $99,850 for men and $73,174 for women. CONCLUSIONS: Major trends evident from this study are subspecialization, medicalization, privatization, feminization, and organizational diversification.     

Do psychotherapists speak to psychopharmacologists? A survey of practicing clinicians

While more Americans are taking psychotropic medication than ever before, psychiatrists are providing less psychotherapy, leading to the prevalence of "split-treatment" whereby two professionals provide care. Communication between clinicians treating the same patient has traditionally been an accepted principle of optimal care, however there has been no published data documenting whether or not private practice therapists actually do communicate with the psychiatrists who prescribe for their patients. A pilot study was conducted in which a nine-item anonymous survey was distributed to non-medical psychotherapists in Manhattan. Information was gathered about professional degree and discipline, duration and size of practice, and frequency of communication with professionals who prescribe for their patients. Fifty-three psychotherapists averaging over 21 years in practice returned completed surveys. Respondents reported on 1,197 psychotherapy patients, with 434 (36%) concurrently taking medication. No communication had taken place between psychotherapist and psychopharmacologist on behalf of 22% of the psychotherapy patients taking medication. Only 7 of the 53 respondents reported having quarterly communication with the prescribing physician for all split-care patients. Despite methodological limitations, study findings document that communication between professionals is not taking place on behalf of many patients in split-treatment. These findings raise questions about the quality and safety of treatment delivered in this fashion, about the need for guidelines for the conduct of split treatment, and perhaps about the traditionally assumed need for communication itself.     

The Senior Psychiatrist Survey II: experience and psychiatric practice.

OBJECTIVE: The aim of this study is to determine the effects of experience on the practice, roles, status and attitudes of psychiatrists within the Royal Australian and New Zealand College of Psychiatrists (RANZCP). METHOD: A postal survey of Fellows of the RANZCP resident in Australia or New Zealand was conducted. The main outcome measures were: years of psychiatric experience; higher medical qualifications; location and type of psychiatric practice; attitudes about senior psychiatrists and mentorship; changes in work practices over the career; and the perceived benefits and drawbacks of experience on psychiatric practice and case selection. RESULTS: Of 1086 eligible subjects, 629 participated. Over 96% of respondents, particularly the younger and less experienced, believed that senior psychiatrists have wisdom to offer to junior colleagues. This wisdom principally related to mentorship/supervision. Increased 'respect and tolerance' of patients as a benefit of experience was more likely to be reported by respondents who were more experienced. Respondents more confident about treating younger patients and treating functional psychoses were more likely to be less experienced, as were those reluctant to take on psychotherapy cases. Those respondents reluctant to take on 'dangerous or acting-out patients' were more experienced. The field of psychiatric practice significantly influenced case selection. CONCLUSIONS: Senior psychiatrists have accumulated wisdom through experience that is sought by junior colleagues via mentorship. It is recommended that the RANZCP should specifically address the needs of early career and senior psychiatrists.     

Child psychiatrists' views of DSM-III-R: a survey of usage and opinions

The DSM-IV Child Psychiatry Work Group surveyed 460 child psychiatrists about their use of DSM-III-R and their reactions to specific proposed nosological revisions for DSM-IV. This paper presents the responses of the sample as a whole and of respondent subgroups with different theoretical, practice, and training characteristics. The survey indicates that DSM-III and DSM-III-R are widely used and generally accepted by child psychiatrists. Ninety-eight percent of respondents believe a criterion-based diagnostic system is useful, and 65% consider DSM-III-R to be an improvement over DSM-III. Depending on the diagnosis 47% to 66% of the respondents reported that they generally assess all applicable criteria and 28% to 49% often refer to the manual before assigning a diagnosis. A majority of respondents supported proposals for several new diagnostic subtypes. Ninety-three percent of respondents indicated that "adequacy of family support" was very valuable for treatment planning or estimating prognosis. Fifty-five percent of respondents admitted to diagnosing adjustment disorders in order to avoid the stigma associated with other disorders. Child psychiatrists who are psychodynamically oriented or practicing in an office-based setting or out of training for more than 10 years tend to use the DSM-III-R less rigorously.     

Functional Neurological Disorders in the medical education: An urgent need to fill the gaps

BackgroundFND is a disabling disease that accounts for 5 to 10% of the reason for consultation in neurology. However, young physicians often say they have little or no training in their management.AimThe aim of the present study was to assess whether French junior neurologists, psychiatrists and physical and rehabilitation medicine (PRM) specialists received teaching on FND during their medical studies, including the residency, and to evaluate their knowledge and perception of the disorder.MethodsThe survey was distributed by the means of a Google form questionnaire to specialist registrars and young specialists with the help of resident's organizations.Results568 respondents from the 3 specialties were included in the study. Most respondents (72.4%) were specialists registrars. Almost half of the respondents (45.5%) answered they never received any teaching on FND, and only 20.5% of them knew the Hoover's sign, a positive sign specific of functional weakness. A large majority of respondents felt they were not sufficiently trained in FND (87.9%), and they did not have sufficient knowledge of these disorders (85.3%).DiscussionBetter training would allow clinicians to make a diagnosis earlier, to better explain it to patients, and to limit the costs associated with diagnosis delays. A better training of clinicians about FND would also improve the prognosis of patients, as early diagnosis and good explanation is associated with a better prognosis.ConclusionThis survey shows that there is a gap about FND in the training programs in the medical studies and during the specialization training of young doctors in France.     

The Canadian Psychiatric Association practice profile survey: I. Methods and general sample characteristics.

OBJECTIVE: To describe the rationale, methodology, and general sample characteristics of the Canadian Psychiatric Association (CPA) practice profile survey, a national survey of psychiatrists and psychiatric practice. METHOD: Mail-in interviews were sent to all Canadian psychiatrists listed in their provincial registers and to all active CPA members (total = 3628). Respondents provided general information about their professional activities for one 24-hour day and detailed information for 1 randomly selected hour. Patient information--including sociodemographics, diagnostic profiles, functioning levels, risk of harm to self or others, and disposition--was elicited for 1 patient seen during the random hour as well as for the most seriously ill patient receiving clinical services that day. RESULTS: There was a 45.5% response rate. Questionnaires completed by nonpsychiatrists or with a large percentage of missing or incorrect data were eliminated (107 surveys), resulting in a final sample size of 1570. CPA members and those from Western Canada responded at a higher rate to the survey. The results suggest some cause for concern about future manpower shortages. Most psychiatrists practise eclectically, seeing patients across the life-span, and working in both community and institutional settings. The old and the young appear to be underserviced, compared with adults. CONCLUSIONS: This study represents an important step forward in evaluating the profile and activities of the profession.     

A view of the prospective child psychiatrist

A questionnaire distributed to the 1,033 medical students who matched into postgraduate year 1 psychiatric positions in 1982 and 1983 obtained data on personal characteristics, career plans before entering medical school, future career plans, attitudes toward personal psychotherapy, and plans for psychotherapy or psychoanalysis during residency. The results for the 579 residents (56%) who responded are reported. The authors explore differences and similarities between respondents who planned to go into general or child psychiatry as they began general psychiatric residency training. They found two clusters of prospective child psychiatrists: one psychoanalytically oriented and the other eclectically oriented. The authors discuss the implications of this clustering.     

Electroconvulsive therapy for minors: experiences and attitudes of child psychiatrists and psychologists.

OBJECTIVE: To estimate knowledge, experience, and attitudes towards the use of electroconvulsive treatment in minors (patients < 18 years of age), among child and adolescent psychiatrists and psychologists. METHOD: 1,600 questionnaires were mailed to a group of child and adolescent psychiatrists and psychologists. RESULT: There were 625 (39%) respondents. 329 (53.8%) of the respondents stated that they possessed minimal knowledge about the use of ECT in children and adolescents. Lack of confidence in providing a second opinion was common and reported by 75%. Compared with those with minimal knowledge, respondents with advanced knowledge reported a higher perception of safety and efficacy. The majority (70%) of the respondents regarded ECT as a treatment of last resort. CONCLUSION: Many child and adolescent psychiatrists and psychologists have very little knowledge, training, or experience in this treatment. They seem to be ill equipped to appropriately consider or advise patients and families about ECT. Clinical and research implications of these findings are discussed.     

Adherence to guidelines by French psychiatrists in their real world of clinical practice

The treatment modalities of bipolar disorder and adherence to international guidelines recommendations in France were investigated. We conducted an observational survey among 210 French psychiatrists concerning their prescribing practice in bipolar disorder, and whether they use guidelines or not. Simple mania is mainly treated with valproate, whereas second-generation antipsychotics are preferred for delusional mania. Lithium is mostly used as second-line treatment by "young psychiatrists." Personal experience appears in the foreground (41% of psychiatrists) in the choice of therapy. Young psychiatrists refer more to guidelines (32% of responders) as compared with other psychiatrists. The main reason for the lack of use of guidelines is because they refer mostly to an Anglo-Saxon medical practice, which is considered different from the French practice. Guidelines for treatment of bipolar disorder are not frequently used. French psychiatrists' age and practice type are the most important variables correlated to the level of use of guidelines.     

Australian psychiatrists today: proud of their profession but stressed and apprehensive about the future

OBJECTIVE: To examine the levels of satisfaction and stress of Australian psychiatrists. METHOD: A survey was mailed in December 2002 to all Fellows of the Royal Australian and New Zealand College of Psychiatrists residing in Australia; 1039 out of 2059 (50%) returned the questionnaire. RESULTS: The large majority of respondents (79%) were proud of being a psychiatrist. Most (88%) reported being satisfied with their work. Reasons for dissatisfaction varied between public and private psychiatrists. Private psychiatrists nominated litigation/indemnity issues as the most frequent (69%) while the most common for public psychiatrists was lack of beds (47%). The main reason for satisfaction was helping patients get better (72%). Sixty-two percent found their work in the previous 12 months to be stressful. Dissatisfied psychiatrists were 11 times as likely to report being stressed as those satisfied. In the previous 12 months, 34% reported having had a threat of legal action, 39% had to answer a formal complaint, 67% had been verbally or physically abused by patients or relatives and 29% had patients who had suicided. Overall, psychiatrists were more pessimistic about the future than optimistic and 15% said they would not do psychiatry again. There were few differences according to state of origin or type of practice. However, females differed from males in several areas. CONCLUSION: Helping patients was reported as the main source of satisfaction for Australian psychiatrists while not being able to provide the best care for patients was described as one of the main reasons for dissatisfaction. Although most Australian psychiatrists are satisfied and proud of their profession, they are stressed and often experience verbal or physical abuse and threats of legal action and complaints. They are apprehensive about the future. The increasing number of females in the profession, their higher levels of stress and dissatisfaction, and other differences from males must be taken into account as the profession reshapes its future. There is a need for regular surveys of this kind.     

Comparing clinic and private practice of psychiatry

The author compared data on 2,020 cases treated by private psychiatrists with those on 2,052 cases treated by clinic psychiatrists in California. He also compared data on private treatment in California with those from a national survey of private psychiatrists. Private psychiatrists in California treated as many psychotic patients and used relatively brief psychotherapy about as often as clinic psychiatrists and were more likely to use hospitalization and to see patients individually. In comparison with the national sample, private psychiatrists in California treated more children and patients with situational disturbances and were more likely to receive payment from government sources.     

The geriatric psychiatry workforce in 2002: analysis from the 2002 National Survey of Psychiatric Practice.

OBJECTIVE: Using the 2002 National Survey of Psychiatric Practice (NSPP), authors update demographic and professional work activities of a nationally representative sample of the psychiatric workforce who treat geriatric patients. METHODS: The sampling frame for the 2002 NSPP used the American Medical Association's Masterfile of Physicians. Professional, demographic, and patient data are compared between general and self-reported geriatric psychiatrists. Authors also present detailed analyses comparing high geriatric providers (HGPs; geriatric caseloads >20%), and board-certified geriatric psychiatrists (BCGPs). RESULTS: The proportion of HGPs in the 2002 NSPP was 26.0% of all respondents and was 28.1% among American Psychiatric Association (APA)-member respondents. Among the APA-member psychiatrists, this reflected a 55% increase from the 1996 NSPP. Of HGPs, 31.0% were certified in geriatric psychiatry. As compared with general psychiatrists, proportionally fewer men and American medical-school graduates were self-reported geriatric psychiatrists. Geriatric psychiatrists saw nearly three times as many geriatric patients and five times as many dementia patients as did their generalist counterparts. Mood-disorder patients were the largest treatment group, however. Investigators observed no significant differences in professional and practice characteristics between HGPs and BCGPs. CONCLUSIONS: About 1 in 4 psychiatrists in the 2002 survey are HGPs. Geriatric psychiatrists treat proportionally more geriatric patients than do generalists, but they do not have exclusively geriatric practices. The similarities between HGPs and BCGPs raise issues about the incentives for geriatric psychiatry certification, but not the need to train subspecialists to serve as faculty and community resources.     

Patients' suicides: frequency and impact on psychiatrists

Results of a national survey of randomly selected psychiatrists revealed that 51% (N = 131) of the 259 respondents had had a patient who committed suicide. This event had an impact on both their personal and their professional lives. Sixty-five psychiatrists reported stress levels in the weeks following the suicide that were comparable to levels reported in studies of people seeking treatment after the death of a parent. Younger, less-experienced clinicians were more affected by a patient's suicide than older clinicians with more experience. Implications of these results for the training and practice of psychiatrists are discussed.     

A cross-sectional survey on French psychiatrists' knowledge and perceptions of psychogenic nonepileptic seizures

ObjectiveThe principal aim of the study was two-fold: to determine French psychiatrists' level of general knowledge of psychogenic nonepileptic seizures (PNES) and to evaluate their perceptions of this condition in a standardized way. The secondary aim was to describe the relationship between level of education and knowledge of PNES and level of experience of case management and perceptions of PNES.MethodsIn this study, psychiatrists were invited by email to answer an online survey. The questionnaire asked about their general knowledge of PNES, and perceptions of PNES were scored using the Brief Illness Perception Questionnaire (Brief IPQ).ResultsWe received 1242 replies, and data from 963 respondents were included. The survey revealed that three-quarters of psychiatrists working in France (75%) had never received any training on PNES, and 42% had never managed patients suffering from PNES. In general, participants considered PNES to be a chronic disease with significant impact on patients' quality of life. Although psychiatrists were aware of the importance of psychological trauma in the etiology of PNES, they showed only moderate understanding of this pathology. Terminology and classification of these disorders were poorly known, and the relation between PNES and histrionic personality was massively overvalued. Prior training on PNES was associated with a better level of knowledge and different perceptions of trained psychiatrists compared with that of psychiatrists with no prior training.ConclusionsThe condition of PNES remains relatively unknown to French psychiatrists, and some of their perceptions were inaccurate. Specific training seems essential for a better understanding of PNES.     

Christian Psychiatry: the impact of evangelical belief on clinical practice

OBJECTIVE: The authors surveyed psychiatrists in the Christian Psychiatry movement to assess the role of religious belief in their practices. METHOD: The psychiatrists were members of the Christian Medical and Dental Society; questionnaires were sent to 260, and usable responses were received from 193. The subjects were asked about demographic and practice variables, "born again" religious experiences, group cohesion, and beliefs about using the Bible and prayer in treatment. RESULTS: The respondents were somewhat more religious than Americans overall, who are themselves more religious than most psychiatrists. Nearly all reported having been "born again," after which they generally experienced a decrease in emotional distress. There was a significant difference in the respondents' affiliative feelings toward psychiatrists in the Christian Psychiatry movement and other psychiatrists. For acute schizophrenic or manic episodes, the respondents considered psychotropic medication the most effective treatment, but they rated the Bible and prayer more highly for suicidal intent, grief reaction, sociopathy, and alcoholism. Whether or not a patient was "committed to Christian beliefs" made a significant difference in whether the respondents would recommend prayer to the patient as treatment. About one-half said they would discourage strongly religious patients from an abortion, homosexual acts, or premarital sex, and about one-third said they would discourage other patients from these activities. CONCLUSIONS: Many studies have suggested a need for more sensitivity to religious issues by psychiatrists, and this study provides systematic findings on one approach. It remains important to evaluate ways in which a religious perspective can be related to clinical practice and what benefits and problems may derive from such a relationship.     

Private and public psychiatry: a comparison of two health care systems

Psychiatrists in Australia and New Zealand are similarly trained, but the health care delivery systems in each country differ. Australia has unlimited insurance for fee-for-service private practice and has twice the psychiatrists and half the psychiatric beds per capita as New Zealand. Psychiatrists in the public sector in each country focus on hospital-based care of psychotic patients. Private-sector psychiatrists, in addition to caring for psychotic patients, also focus on psychotherapy for neuroses and personality disorders. The Australian combination of more psychiatrists in private office practice and fewer public hospital beds costs less than the New Zealand system, which supports only public-sector, hospital-based services.     

Psychiatrists and psychotherapy: Guidelines for future development

Since1986 basic training in psychotherapy is obligatory for physicians specializing in psychiatry. Whereas the vast majority of Swedish psychiatrists recognize psychotherapy as important and the course has been well received, there are still problems that demand attention. The following policy document by the Swedish Psychiatric Association (SPF) aims to influence the authorities involved in implementing necessary reforms: Psychotherapy is psychologic treatment with a health objective and as such should be covered by the same requirements with regard to safe care as other forms of medicine. All public psychotherapy should be supervised by a senior consultant. Although the official policy of the authorities is that psychiatrists should acquire psychotherapy skills, the practical measures taken have been counterproductive. The SPF suggests that medical posts be created for specialists in psychologic psychiatry; the possibility of combining practice in the private and public sectors be reopened; psychiatrists in the public sector be given the possibility of practising psychotherapy; and psychiatrists be given the right to train as psychotherapists. The present obligatory course needs to be modernized. The SPF suggests that the course be lengthened; a requirement of approved supervision be introduced; control of the clinics involved in training be introduced; steps be taken to ensure that the obligatory course gives due attention to the dynamics of the patient-physician relationship. A recent investigation showed that less than one-fourth of patients in need of psychotherapy were receiving treatment. The training volume of psychotherapists needs to be expanded. The SPF urges the national authorities to open a fourth training centre complementing the existing three psychodynamically based programmes with one in cognitive therapy.